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, <br /> -�- <br /> z �� �� , ., .� �� /-�/�- <br /> Date—'_L_;� �'ublic�9orY.c Peimi�u <br /> Application For em�.pe❑�.n�� � L� <br /> (l - � . �t��.� <br /> P!! �L.I C OIVO R KS P E R M i�' Public Works Fee � <br /> Tatal Fco $ <br /> Loss ADOL Fee Paltl S <br /> Balance Oue �u '?��- <br /> Print or Type Only <br /> � <br /> ;r�F �<_ II��<<-c. ��I�=�.�� l�r�,��i��v' � %,!f���_rr- �i,�'ac! I �>,�- r �� i �I <br /> Owner Mailing Address � Cily Zip Phone <br /> (���"��`�C' . <br /> Applicant Mailing Address City Zip. Phone <br /> C <br /> Describe ProPosed Work /�4r� .L� .� � �� F-X l� C�S I�},� �.� � �1 /J �c_.��%_ `�.tt� �-1� ' <br /> � , <br /> �h � �' <br /> Project Address(if known) �/�2/ � �' h^' /.3 sy`: � I <br /> Attach four(4) copies o( plans tor propesed work- Draw lo scale and note the followiny as apGlicable: � ' <br /> • Property Lines • Centerline of sVeet � <br /> • Outline and dimensions ol all existing and • Indicate North <br /> proposed structures on the lot • Show any proposed grading changes <br /> • Existing and proposed utilities • Show measurements � <br /> DO NOT`NRITE BELOW THIS LINE <br /> PERMIT CONDITIONS � <br /> t. All calis for inspection shall be ma�e 24 hrs. in advance- phone 259-8815. � <br /> .i. All work shall be performed in accordance wi�h Ihis permit and current City ol Evere�� Design and Conslruction <br /> Standards and Specifications. <br /> 3. Call Location Underground Service 48 hrs. I�efore you dig 70LL FREE NUMBER 1-800-424-5555. � <br /> � <br /> �w <br /> _/ <br /> � <br /> � <br /> � ACK�OWLEDGEMENT OF CONDITIONS <br /> � The undcrsioned owner/applicant hereby agrees to hcld and save harm- <br /> less thc City o( Everet� from any and all claims lor damayes, costs, <br /> � . , �.'_ �yr_ _�� expenses. or causes of action that may arise because of installalion <br /> , ��� ' � �- .�,¢. and maintenance of ihe improvement or olher righPo(-way use nereto <br /> " �-.. .,f-'. �•�/i:_-- r_ <br /> APProved (or Constructio Date �PPlied tor and further ayrees to remove same upon notice Irom ihe <br /> City and to replace public property damaged thereby. <br /> � % 'OZ C��� , f�� � <br /> FiNn—�irvs�crioN ' oaie /���.:_— G ;���7` �S-� �Y�, <br /> Approved as Constructed Signature of Applicant �Date <br /> everett PUBLIC WORKS DEPARTMENT WORI< AUTHORIZED 6Y THIS PERMIT MUST BE STARTED WI7HIN <br /> � 3200 Cedar Street 180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br /> Everett, WA 98201 BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT P.1AY BE <br /> Phone: 259�8&1��y�QC CANC[LLED BY THE CITY UPON ANY STOPPAGE OF WORI(ON THIS <br /> PROJECT OVER 90 DAYS DURATION. <br />